| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01G011 | (X3) Date Survey Completed 10/04/2025 |
| Name of Provider or Supplier Rainbow Omega, Inc, | Street Address, City, State 202 Hope Drive, Eastaboga, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| W0195 | ACTIVE TREATMENT SERVICES CFR(s): 483.440 The facility must ensure that specific active treatment services requirements are met. This CONDITION is not met as evidenced by: Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure clients were provided a continuous and aggressive active treatment program which included a day training program. The facility failed to have all facets for clients to obtain and maintain the independence and autonomy to live a normal adult life. These failures negatively impacted all 15 clients who resided at the facility. On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures constituted Immediate Jeopardy related to the facility's failure to have a continuous and aggressive active treatment program.. It was determined the Immediate Jeopardy existed on 07/14/23 when the facility failed to provide an active day training program. The facility presented an acceptable plan of removal of the Immediate Jeopardy on 10/04/25 at 2:35 PM. The facility's removal plan included: 1. The facility Director and a part-time Qualified Intellectual and Disability Professional (QIDP) will cover the functions of a QIDP until a candidate who meets the minimum requirements is hired. 2. The facility Director and part-time QIDP will complete an updated Comprehensive Functional Assessment (CFA), including having the vocational section completed by a qualified individual on all 15 clients who reside at the facility. 3. The facility is in the process of developing a day treatment program to fit each clients' need based on the CFA to ensure all 15 clients who reside at the facility receive continuous active treatment. 4. The facility Director has consulted with a Board-Certified Behavior Analyst (BCBA) to ensure clients have the behavior supports and services needed including having a comprehensive behavioral assessment to determine if and what behavioral supports clients may need. Through interview and record review, the survey team validated the facility began the implementation of all components of the removal plan, and the Immediately Jeopardy was removed on 10/04/25 at 6:15 PM. Findings include: 1. The facility failed to ensure each client received a continuous and aggressive active treatment program to acquire behaviors and skills to live an independent life as possible that mirrored a normal living experience as much as possible for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility failed to have a Qualified Intellectual Disability Professional (QIDP) to ensure the facility had a day training program for the clients to obtain or maintain vocational skills and promote vocational readiness with an on the job training program, and/or other program bases on a Comprehensive Functional Assessment (CFA) completed by a person or persons with the competency needed to complete all sections of the CFA including the Vocational section. Thes failures negatively impacted all 15 clients of the facility. Cross Reference: W196. 2. The facility failed to ensure the comprehensive functional assessment (CFA) for one of eight clients (Client (C) 2) addressed specific behavioral supports needed to address aggressive behavior towards himself/herself or others. The Qualified Intellectual Disability Professional (QIDP) was aware of C2's high frequency in self-injurious behavior (SIB) and physical aggression towards others; however, the CFA did not include a functional behavioral assessment or a referral for a functional behavioral assessment completed by a qualifying professional. This failure impaired C2's everyday life and the client was neglected during SIB episodes, which eventually caused actual harm to the client. Cross Reference: W214. 3. The facility failed to ensure the CFA included an individualized vocational assessment for all domains for what skills clients can and cannot do and addressed job sampling, job development, on-site job training, and long term follow-up for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility did not have a day training program for clients to be able to be properly assessed, learn new skills, and maintain the skills they have. This failure had the potential to negatively impact all 15 clients who resided at the facility. Cross Reference: W225. 4. The facility failed to ensure the Human Rights Committee (HRC) approved all client restrictions before the restrictions were imposed for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The clients did not have freedom of movement to access common areas of their home. Clients were restricted from their kitchen; and the clients' front door to their home was equipped with delayed egress locking hardware and required a key code to exit. These restrictions were not taken before the HRC, and clients were not afforded due process. Additionally, the right restrictions approved by the HRC and identified in the clients' CFA did not include a behavior plan which included a rights restoration plan. These restrictions affected all 15 clients who resided in the home. Cross Reference: W262. Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure clients were provided a continuous and aggressive active treatment program which included a day training program. The facility failed to have all facets for clients to obtain and maintain the independence and autonomy to live a normal adult life. These failures negatively impacted all 15 clients who resided at the facility. On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures constituted Immediate Jeopardy related to the facility's failure to have a continuous and aggressive active treatment program.. It was determined the Immediate Jeopardy existed on 07/14/23 when the facility failed to provide an active day training program. Findings include: 1. The facility failed to ensure each client received a continuous and aggressive active treatment program to acquire behaviors and skills to live an independent life as possible that mirrored a normal living experience as much as possible for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility failed to have a Qualified Intellectual Disability Professional (QIDP) to ensure the facility had a day training program for the clients to obtain or maintain vocational skills and promote vocational readiness with an on the job training program, and/or other program bases on a Comprehensive Functional Assessment (CFA) completed by a person or persons with the competency needed to complete all sections of the CFA including the Vocational section. Thes failures negatively impacted all 15 clients of the facility. Cross Reference: W196. 2. The facility failed to ensure the comprehensive functional assessment (CFA) for one of eight clients (Client (C) 2) addressed specific behavioral supports needed to address aggressive behavior towards himself/herself or others. The Qualified Intellectual Disability Professional (QIDP) was aware of C2's high frequency in self-injurious behavior (SIB) and physical aggression towards others; however, the CFA did not include a functional behavioral assessment or a referral for a functional behavioral assessment completed by a qualifying professional. This failure impaired C2's everyday life and the client was neglected during SIB episodes, which eventually caused actual harm to the client. Cross Reference: W214. 3. The facility failed to ensure the CFA included an individualized vocational assessment for all domains for what skills clients can and cannot do and addressed job sampling, job development, on-site job training, and long term follow-up for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility did not have a day training program for clients to be able to be properly assessed, learn new skills, and maintain the skills they have. This failure had the potential to negatively impact all 15 clients who resided at the facility. Cross Reference: W225. 4. The facility failed to ensure the Human Rights Committee (HRC) approved all client restrictions before the restrictions were imposed for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The clients did not have freedom of movement to access common areas of their home. Clients were restricted from their kitchen; and the clients' front door to their home was equipped with delayed egress locking hardware and required a key code to exit. These restrictions were not taken before the HRC, and clients were not afforded due process. Additionally, the right restrictions approved by the HRC and identified in the clients' CFA did not include a behavior plan which included a rights restoration plan. These restrictions affected all 15 clients who resided in the home. Cross Reference: W262. ********************************** The facility presented an acceptable plan of removal of the Immediate Jeopardy on 10/04/25 at 2:35 PM. The facility's removal plan included: 1. The facility Director and a part-time Qualified Intellectual and Disability Professional (QIDP) will cover the functions of a QIDP until a candidate who meets the minimum requirements is hired. 2. The facility Director and part-time QIDP will complete an updated Comprehensive Functional Assessment (CFA), including having the vocational section completed by a qualified individual on all 15 clients who reside at the facility. 3. The facility is in the process of developing a day treatment program to fit each clients' need based on the CFA to ensure all 15 clients who reside at the facility receive continuous active treatment. 4. The facility Director has consulted with a Board-Certified Behavior Analyst (BCBA) to ensure clients have the behavior supports and services needed including having a comprehensive behavioral assessment to determine if and what behavioral supports clients may need. Through interview and record review, the survey team validated the facility began the implementation of all components of the removal plan, and the Immediately Jeopardy was removed on 10/04/25. |